Provider Demographics
NPI:1649321944
Name:GLENN, DONALD M (PA-C)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:M
Last Name:GLENN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3726
Mailing Address - Country:US
Mailing Address - Phone:773-275-7700
Mailing Address - Fax:
Practice Address - Street 1:4025 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3726
Practice Address - Country:US
Practice Address - Phone:773-275-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23416Medicare ID - Type UnspecifiedMEDICARE DON GLENN
COP50366Medicare UPIN